gagal jantung - dr. andreas arie, sppd-kkv

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5/13/2014 1 HEART FAILURE Dr. Andreas Arie, SpPD-KKV CARDIOVASCULAR DIVISION INTERNAL MEDICINE DEPARTMENT MEDICAL FACULTY DIPONEGORO UNIVERSITY DEFINISI GAGAL JANTUNG DEFINISI GAGAL JANTUNG - suatu keadaan patofisiologis di mana jantung tidak mampu memompa darah sesuai kebutuhan metabolisme jaringan, atau untuk memenuhi kebutuhan jaringan harus meningkatkan tekanan pengisian. - gagal jantung adalah suatu sindroma klinik yang kompleks akibat gangguan fungsional/ struktural jantung yang mengganggu kemampuan pengisian/ memompa ventrikel.

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Page 1: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

5/13/2014

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HEART FAILURE

Dr. Andreas Arie, SpPD-KKV

CARDIOVASCULAR DIVISION INTERNAL MEDICINE DEPARTMENT

MEDICAL FACULTY DIPONEGORO UNIVERSITY

DEFINISI GAGAL JANTUNGDEFINISI GAGAL JANTUNG

- suatu keadaan patofisiologis di mana jantung tidak mampu memompa darah sesuai kebutuhan metabolisme jaringan, atau untuk memenuhi kebutuhan jaringan harus meningkatkan tekanan pengisian.

- gagal jantung adalah suatu sindroma klinik yang kompleks akibat gangguan fungsional/ struktural jantung yang mengganggu kemampuan pengisian/ memompa ventrikel.

Page 2: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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DEFINISI GAGAL JANTUNGDEFINISI GAGAL JANTUNG

Gagal Jantung merupakan akhir dari beberapa penyakit jantung :

PENYAKIT JANTUNG BAWAAN

PENYAKIT JANTUNG KATUP

PENYAKIT JANTUNG KARDIOMIOPATI

PENYAKIT JANTUNG KORONER

PENYAKIT JANTUNG HIPERTENSI

LV dilatation

Activation of Neurohormonal Pathways in HFActivation of Neurohormonal Pathways in HF

Coronary Disease Cardiomyopathy Cardiac Overload

Left Ventricular Dysfunction

Neurohormonal Activation• Cathecholamines• RAS• AVP• Endothelin

Cardiac RemodellingPeripheral OrganBlood Flow

Vasoconstriction

skeletalmuscle flow

RBFNa+ retention

LV hypertrophy

Arrhythmias

Exercise Intolerance Edema, Congestion Sudden Death Pump Failure

Ruffolo, J Cardiovasc, Pharmachol, 1998

Page 3: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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Pathophysiology of CHFPathophysiology of CHFInjury to myocytes

and EC matrix

Electrical, vascular, renal,pulmonary, muscle effects

CHF

Ventricularremodelling

Neurohumoral activationIncreased cytokines

Immune andinflammatory changes

altered fibrinolysis

Oxidative stressApoptosis

Altered geneExpression

Energy starvation

McMurray J, Pfeffer M. Circulation. 2002 (in press)

• Neurohormonal stimulation

• Endothelial dysfunction

• Vasoconstriction

• Renal sodium retention

Progression of Cardiovascular DiseaseProgression of Cardiovascular DiseaseCoronary

arterydisease

Hypertension Arrhythmia

Left ventricularremodeling Remodeling Low ejection

fraction Death

PumpfailureCardiomyopathy Valvular

disease

(Abraham, 2000)

Noncardiacfactors

Symptoms:DyspneaFatigueEdema

Chronicheart

failure

Page 4: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

5/13/2014

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Framingham criteria for Congestive Heart Failure

Definite : - 2 major

- 1 major + 2 minor

Major Criteria Minor Criteria

Paroxysmal nocturnal dyspnea

Neck-vein distension

Rales

Acute pulmonary edema

S3 gallop

Increased venous pressure

> 16 cm H2O

Circulation time > 25 sec

Hepatojugular reflux

Ankle edema

Night cough

Dyspnea on exertion

Hepatomegaly

Pleural effusion

Vital capacity increased 1/3 from

maximun

Tachycardia ( rate > 120/min)

Major or Minor Criteria

Weight loss > 4.5 kg in 5 days in response to treatment

Gagal Jantung

Page 5: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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New York Heart Association Functional ClassificationClass I: No symptoms with ordinary activity

Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina

Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in

fatigue, palpitation, dyspnea, or anginal pain

Class IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest

NORMAL

Asymptomatic LV Dysfunction

CompensatedCHF

DecompensatedCHF

No symptomsNormal exerciseNormal LV fx

No symptomsNormal exerciseAbnormal LV fx

No symptomsExercise

Abnormal LV fx

SymptomsExercise

Abnormal LV fx

RefractoryCHF

Symptoms not controlled with treatment

Chronic Congestive Heart Failure

Evolution of Clinical Stages

Page 6: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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Stages Examples

Stage A: At high risk for HF but without structural heart disease or symptoms of HF

HTN, CAD, DM, cardiotoxins, FHx of CM

Stage B: Structural heart disease but without symptoms of HF

Previous MI, LV systolic dysfunction, asymptomatic valvular disease

Stage C: Structural heart disease with prior or current symptoms of HF

Known structural heart disease, SOB and fatigue, reduced exercise tolerance

Stage D: Refractory HF requiring specialized interventions

Marked symptoms at rest despite maximal medical therapy

Stages of Heart Failure

ACC/AHA Heart Failure Practice Guidelines 2001

Klasifikasi Killip: (klinis)

�� Stadium IStadium I : tak ada tanda-tanda gagal jantung (IMA 85%)

�� Stadium IIStadium II : didapat tanda-tanda gagal jantung

awal berupa ronki di paru, gallop S3.

�� Stadium IIIStadium III : gagal jantung berat yaitu terjadi

edema pada seluruh lapangan paru

�� Stadium IVStadium IV : terjadi syok kardiogenik berupa

hipotensi (tekanan sistolik < 90

mmHg), nadi cepat, ekstremitas

dingin, oliguria, sianosis.

Page 7: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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DIET Approach to the Patient With Heart Failure

• Diagnose– Etiology

– Severity (LV dysfunction)

• Initiate– Diuretic/ACE inhibitor

– β-blocker

– Spirololactone

– Digoxin

• Educate– Diet

– Exercise

– Lifestyle

– CV Risk

• Titrate– Optimize ACE inhibitor

– Optimize β-blocker

The Clinical History in Heart Failure Specific History to Obtain*

• Cardiovascular

� Angina Pectoris

� Nonspesific chest pain

syndromes

� Fatique

� Weakness

� Orthostatic faintness

� Palpitations

� Rheumatic disease

� Congenital disease

• Pulmonary

� Dyspnea on exertion (DOE)

� Orthopnea (OP)

� Paroxysmal nocturnal dyspnea (PND)

� Periodic respirations

� Nocturnal apnea

� Snoring

� Pleurisy

� Cough

� Hemoptysis

� Wheezing

Page 8: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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• Gastroenterologic

�Abdominal pain

�Abdominal bloating

�Constipation / diarrhea

�Anorexia

� Nausea

�Vomiting

• Neurologic

�Anxiety or panic

� Depression

�Confusion

� Decreased mental acuity

• Renal

� Nocturia

�Oliguria

• Systemic

� Edema

� Petechiae / ecchymosis

�Weight gain / loss

Specific History to Obtain*

Physical examination of Heart Failure PatientsSpecific physical findings to pursue*

•Vital sign

� Positional blood pressure

� Blood pressure response

during valsalva

� Pulse rate, rhythm, and quality

� Respiratory rate and pattern

�Temperature

• Cardiovascular

� Neck vein distention

�Abdominal-jugular neck vein reflex

�Cardiomegaly on palpation

� Displaced, sustained, or

hyperkinetic apical impulse

�Chest wall pulsatile activity

�Gallop rhythm on auscultation

� Heart murmur (especially mitral,

tricuspid, and pulmonic insuf.)

� Diminished S1 or S2

� Friction rubs

Page 9: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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PENUNJANG

� Lab :

Leucocytosis, Urine : Oligouria

� ECG :

Dysrythmia, LVH, RVH, IHD, Tachicardia,

� Chest X-Ray :

� Cardiomegaly

� Inceased Bronchovascular Marking

� Alveolar Edema

� Pleural Efusion

� ‘Bat-Wing’ App / Kerley B-Lines

� Echocardioghraphy

Suspected acute heart failureAssess symptoms and signs

Consider other

diagnosis

normalHeart disease ?ECG / X-ray / BNP/NT-proBNP ?

abnormal

Evaluate cardiac function by echocardiography/other imaging

… continue

ESC guidelines on the diagnosis of acute heart failure

abnormal

normal

European Heart Journal 2005; 26:1115

Page 10: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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Stages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stage

Pts with:• Hypertension• CAD• DM• Cardiotoxins• FHx CM

THERAPY

• Treat Hypertension• Stop smoking

cessation• Treat lipid disorders• Encourage regular

exercise• Stop alcohol &

drug use• ACE inhibition

THERAPY

• All measures under stage A

• ACE inhibitor• Beta-blockers

THERAPY

• All measures under stage A

• Drugs for routine use:• diuretic• ACE inhibitor• Beta-blockers• digitalis

THERAPY

• All measures under stage A, B and C

• Mechanical assist device

• Heart transplantation• Continuous IV

inotrophic infusions for palliation

Stage A Stage B Stage C Stage D

Struct.Heart

Disease

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Pts with:• Previous MI• LV systolic

dysfunction• Asymptomatic

Valvular disease

Develop.Symp. of

HF

Pts with:• Struct. HD• Shortness of

breath and fatigue,reduce exercisetolerance

Refract.Symp. ofHF at rest

Pts who havemarked symptomsat rest despitemaximal medicaltherapy

The Donkey Analogy

Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

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Digitalis Compounds

Like the carrot placed in front of the donkey

Diuretics, ACE Inhibitors

Reduce the number of sacks on the wagon

Page 12: Gagal Jantung - Dr. Andreas Arie, SpPD-KKV

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Management of Heart FailurePrimary Targets of Treatment in Heart Failure.

ATAS PERHATIANNYAATAS PERHATIANNYAATAS PERHATIANNYAATAS PERHATIANNYA